 Good afternoon, I can't see you, to be fairly honest, but I can hear you, I hope so. Thank you! Right, I'm here today more or less on behalf of the European Society of Anesthesiology, but I'm giving you my perspective. And I hope you don't mind, I walk a little bit around, I hope you can still hear me, I don't have anything written down, but I would like to start with a little story. And imagine, go back in the 50s, in 1952, there was a large polymyelitis epidemic in Copenhagen. Over 5,700 people were registered and came to one hospital. And almost two and a half thousand patients were experiencing respiratory or bulba failure. So basically they weren't able to breathe anymore. Can you imagine this? And the hospital was equipped only with one eye and lung and six churras respirators. That's it! So can you imagine seven devices versus two and a half thousand patients needing these devices? It's impossible! What a disaster! And now I would like to share with you a true story. And it's the original notes of Vivi. Vivi is a 12-year-old girl who also has been admitted to the hospital with fever and paralysis. And you see on the right side, if you go to the Copenhagen archive, you can find these notes. So this girl was basically doomed to die. Couldn't breathe anymore. And there was one clever guy, Dr. Ibsen. He was the first anesthetist of Denmark. But I'll let you know, he was trained in the US. And he saw all the problems. All the children, young people were dying because they haven't had any idea how to treat it. So he thought we do a tracheotomy that means a little hole here in the neck region and put a tube in and ventilate the patients. So the whole group in the hospital said, wow, that's quite interesting approach and attempt. They all went to the room where this little girl was waiting. And then they put some local anesthetic there and the girl, she went into mucus, into spasm, went pale, went blue and was basically almost dying. So all the people, all the group of doctors and so on left the room because they thought, oh, she will die anyway. The only person who stayed in the room was the anesthetist, Dr. Ibsen. And he injected 100 milligrams of sire pental. The tracheotomy was performed and the girl was ventilated and she survived. That is the start. This is an amazing story. And this tells you now where we're going to head because, can you imagine, 300 cases of polio every week in one hospital, the mortality rate was 90%. And the guy, Dr. Ibsen, had the idea, let's put a little hole in the neck and ventilate them. But there was further ideas because, number one, they recruited 1,500 medical students. And these students, they did nothing else than for 286 days, having a little back in their hand and ventilating patients. 165,000 ventilation hours. It's unbelievable. But what do you think? What happened with the mortality? We're here at a patient safety movement meeting. It went down to 25%. Is this not amazing? 90 to 25? And you see the little picture here on the right side. This was a reality at the time. So, patients were conscious. They were laughing, they were smiling, but they were just unable to move and to breathe. And you see the little books here? So the medical students had on one hand a little back ventilating. On the other hand, they were reading children books and so on. So I think it's just an amazing story. But the birth of intensive care medicine is not only related to this story. It's a little bit more because even at the time, intensive care medicine or the birth was really lucky. Why was it lucky? Because there were three guys, Astro, Sikert, Anderson, Severinghaus, who invented the PH, PCU2 and oxygen electrodes. But why did they develop it for medicine? No, not for medicine. It was for the Danish brewing industry. And you all know Kalsberg. It's a beer company. They're producing beer. So they were developing something for a completely different purpose. But then it was used for medicine. And suddenly long-term ventilation was now possible. And I would like to read to you the sentence because Dr. Ibsen said, if a patient comes now to my intensive care unit, the patient needs to be more abundant. So he was saying, I wanted to make sure that if the patient recovered, it would be recognized as due to our treatment. And if that, if he did not recover, our treatment would not be blamed. So the lessons to be learned is the history of intensive care medicine, at least in Europe, should not be forgotten. And Dr. Ibsen had the idea that patient care on a unit like this needs to be excellent. And he said, one patient, one nurse in a dedicated ward. We have heard today that cutting cost means taking a little bit stuff out, less nurses, less doctors. This is not a solution and definitely not for patient safety. So in 1953, the speciality of intensive care was born. And my statement is a very strong one at the end of my slide. Anesthesia and intensive care medicine cannot be separated from each other. And I'm standing here as a representative for the European Society of Anesthesiology, and this will be further developed in our society. So what else then our society for at, it's very simple, we treat patients and we want to make sure that they're safe. So patient safety in anesthesiology is one of the major aims and goals within Europe. And I would like to give you this example, the five R's, the right drug, the right route, the right time, the right dose, the right patient. I'm very positive. That's the reason why I'm saying this. I don't, I'm not negative. I don't want to say the wrong drug, the wrong route, the wrong time, the wrong dose, the wrong patient. That's awful. No, the right things to do. And it's important that we use standardized syringe labels. And I hope you all do this in your hospitals, because this prevents patient dramas, patient damage, death, whatsoever. So this is just an example how things could work. But I also would like to talk about what our society is promoting clinical research. And a very good example is the apricot trial. Anesthesia practice in children, observational trial. This was being carried out in Europe with over 30,000 children have been observed with the age of zero to 15. And the hypothesis was to study the incidence of severe critical events. And in children, it's like laryngo and bronchospacin, aspiration, neurological damage, cardiac arrest, death, and so on. And if you look at the numbers now, it's quite worrying because severe critical events, 5.2% and all cause 30 day in hospital mortality, one in a thousand. And this was independent of the type of anesthesia. So what can we learn from this? Education, education. We have to improve quality in pediatric anesthesia. And this is a difficult task. But children are not half adults. No, they're very special. They're very particular. And they need special care from specialists. And this needs education, but needs also awareness. So I would like to give you an example from our own hospital. What you see on the left side is theater. You see a ventilator. And you see this little glass picture. This has been developed from one of our consultants. And it's basically glass. And before anesthesia is being carried out, the team has to stand still and to write down all the relevant things which might be important for anesthesia. So it's weight, different doses of medication. And you see the labels here are also the same labels also on the syringes. So to make sure that no mistake can happen if a situation is not going straightforward. And it needs to be signed by the anesthetist and signed by the consultant just to make sure safety is present. It can be wiped after that. So it can be reused. The other thing, what we have introduced is anesthesia trolleys. And an anesthesia trolley with medication for adults cannot be used for children. Therefore, we're using these nice pinkish ones for children. So it's a completely different setup. And it's a commitment from us to make sure that we are not providing situations where doctors can make mistakes. And we want to see happy babies. This actually is my daughter, but this is five years ago. Right. The next thing I would like to talk briefly about, you have heard it already is anemia. Anemia is a decrease in a total amount of red blood cells or hemoglobin and the blood. And we all know patients coming to the hospital to be treated to be healed. But I'm telling you something, you can agree or disagree with me. The biggest enemy of a patient is the hospital, unfortunately. So we have to make the big enemy safe. Why do we have to do this? Because I'm saying the biggest enemy because the patient is coming already with anemia. And we are making it worse. So we have to change this. So why is anemia so bad, especially in the preoperative setting? So if you coming to have elective surgery, we know now that anemia is associated with a 20% longer hospital stay, a twofold increase risk of infection, a four times increased risk of kidney injury, a threefold increased risk of mortality, and five times increased risk of transfusion. So why do we allow patients for elective surgery to be anemic? This is a no go. And that's the reason why we have the apps number five that we prevent this. We have to stand up as a hospital as health professionals, not allowing this to happen. Now I will be a little bit provocative. And I would like to get you into a different thinking. We all respect the WHO, the World Health Organization. They're doing brilliant work, fantastic job. But if you look at this year, you have children, you have women, you have men, and we have hemoglobin thresholds. And these thresholds are being used to say a person is anemic or not anemic. And if you look at this, women not pregnant, they say it's 12 and men 13. These numbers and data are about 60 years old. And what it does, I'll show you with the next slide. Now imagine you're part of a team operating in the theater. And you have on one side, a young man. His hemoglobin is 13. So he's by definition not anemic. His blood volume is 6.5 liters. And he has his undergoing surgery and losing one liter of blood. His hemoglobin is going down to 11. Second situation, a young lady, or an elderly lady in this case, hemoglobin is 12. She's not anemic by definition. But her blood volume is only 2.6 liters. She's tiny, she's small. And she also bleeds one liter. And a hemoglobin is seven. What do you think is the difference now? It's very simple. The lady will be transfused. Everything is the same, same operation, same surgeon, same amount of blood loss. But this lady needs to be transfused. What can we change? And I'm telling you what we need to do is we have to treat men and women equal. Why should we put women in a, I would say, in a bad situation before we even do surgery? And that's what I'm showing you here. We call it version 4.0 for plant surgery. And what you see here is we do not make any difference anymore between men and women on the hemoglobin concentration. So I believe we as men have to carry women on our arms. We have to treat them like queens at home and in the hospital. I hope you agree with me. So translating this now in the real world is the following. So if we agree women should have an hemoglobin also of 13. The blood volume stays the same. The same amount of blood has been lost. And suddenly the hemoglobin is eight. And that means no transfusion. And as you know, transfusion has a lot of risk. And I don't want that our better side in the human race is being harmed by something which is unnecessary. Implementing patient blood management has a huge impact on patients. And some years ago here, the patient safety movement, we presented the work. And it's very simple. Optimize hemoglobin, use blood sparing techniques and use standardized transfusion protocols. And you need at least 20% less transfusion. And you have a reduction in complications. So there's no way out of not using patient blood management. I don't know who has been in theater the last five years, but this has changed dramatically. This is modern anesthesia. This is actually one of our theaters in Frankfurt. You see the person in green that's the anesthetist. And he's surrounded by a lot of medical devices, helping to make better medicine. But sometimes we forget the patient. The patient is right here. They are the patient. And you can see it's very technical. So we need industry to help us to get all the information together to make better decisions. The same thing on the intensive care unit. There's the patient on our unit. And again, you see, he's surrounded by lots of things. And I'm highlighting it. The patient is on a ventilator. The patient is monitored. The patient is on a huge battery of drugs being perfused in the body. Unfortunately, the kidneys are not working anymore. So we have dialysis. We have a weakness of the heart as a balloon pump in the patient. And last, the patient is also on an ECMO to provide further oxygen for the circulation. This is the medicine surrounding we experiencing every day. And this is also something the European Society of Anesthesiology is facing. How do we get our trainees into this? How do we make sure that they know what to do and they're confident in what they're doing? And I would like to come to a trial which the European Society of Anesthesiology has carried out together with the European Society of Intensive Care Medicine. It's the European surgical outcome study. And almost 500 hospitals have been involved in 28 countries. And 46,000 patients have been admitted, were involved and 77% of these have been admitted to critical care. And the mortality is interesting. If it were elective, 3.2%, emergencies almost 10%. However, 73% of deaths have never been admitted to critical care. Demonstrating that if a country, if a hospital has not this facility, patients will have bad outcome. So I'm promoting to have enough critical care capacities to treat patients in the case of elective or emergency. And what is also interesting in this study, you can see here, is this your adjusted odds ratio, the outcome. So if you use your reference, this is United Kingdom, it's right in the middle. If you have countries on the right side, you can see patients had a worse outcome. If you go to the left side, patients had a better outcome. So there's a huge virality in providing proper care, and especially in intensive care medicine. So we should be aware of that there's a lot of things which need to be done in terms of training, but also in terms of how medicine is being implemented in intensive care. I'm coming to a point which is in my eyes absolutely important, training. And I have used the word preparing for the future. We have not so many very, very young people here. I know there's some in the first lane here. But medicine is a great, great field. And going to medical school is fun on one side. On the other side, you're being prepared for real life. But we have a change, at least in Europe. Our young people are not anymore prepared to work as much as we did. And they also are, I think, extremely clever, because they were growing up with computers. They were growing up with electronic learning skills and so on and so on. And they have valid points that we have a family shift work is not good as unhealthy for us on calls is unhealthy. And I would like to be at Christmas, Easter and Thanksgiving at home. Make sense. Make sense to all of us, I think. On the other side, we have to consider this. And how do we provide health care for our patients if the young people do not want to work anymore on these particular days? Do you have any ideas? So that brings me to a point and which is intensive care medicine. As you know, in intensive care medicine, you have to work day in, day out 24-7. You're working in shifts. In my department, on the intensive care unit, our doctors are working 12-hour shifts. So they have one week they're working four days, and the other week they're working three days. And it's not very helpful to have a family or girlfriend or boyfriend, because I think it's crazy. But we know that the number of intensive care beds are increasing in Europe. They have to increase because our society is getting older. So how do we want to run these beds when we have less people who would like to work on intensive care medicine? So the only option I personally see is we have to have models where we have young doctors working on the intensive care unit for a certain time, and then doing something else and coming back. This model, I think, is only being possible by combining anesthesia and intensive care medicine. Ladies and gentlemen, I hope I've given you a very, very, hopefully nice insight about the European society, what we're planning to do. This is just on the surface, but it tells you we care for patient safety. We care for our patients. But also you need to know it is sometimes extremely difficult. If a patient comes to you and you induce anesthesia and the patient never wakes up again, then you know something needs to be done. And I'm very grateful today for the platform I have here to present the European society. And I would like to say for the first time today, thank you to the family behind Joe Chiani, because without the family behind all these things wouldn't be possible as well, especially your wife. And yes, I hope you enjoyed this. And if there's any questions later on in the evening, please come to me. Thank you very much.